Psychiatrists are starting to question whether some forms of depression are
better treated with therapy

This year marks the 25th anniversary of the launch of Prozac, the first of the selective serotonin re-uptake inhibitors, or SSRIs – the most successful class of drugs ever marketed for the treatment of mental illness. Its launch tripled the number in Britain taking “happy pills” from one to three million. This achievement, in making so many more cheerful than they would have been, should be a cause for celebration. Bryony Gordon wrote from personal experience in this paper recently that the drug provided the foundation for her recovery from severe obsessive-compulsive disorder and depression.

Psychiatrists, perhaps surprisingly, are more sceptical, with an article on the anniversary in the British Journal of Psychiatry by Prof Edward Shorter asking: “Where did we go wrong?” He provides a two-part answer.

At one time, psychiatrists made a distinction between two types of depressive illness: melancholia, a severe, protracted, often lifelong gloominess of the spirit; and the more common “reactive” depression, whose similar but less severe symptoms are usually in response to an adverse life event, such as unemployment, marital breakdown or bereavement. Back in 1980, the American Psychiatric Association abolished this distinction in favour of seeing depression on a continuum, more serious in some than others, but always responsive to medication.

Next, Prof Shorter argues that psychiatrists were too readily seduced by claims that Prozac-like drugs have a specific mechanism of action, improving mood by boosting the levels of serotonin in the brain. In reality, scientific understanding of the role of transmitters in mental illness was, and remains, “trivial”.

The ascendancy of SSRIs has concealed what an earlier generation of psychiatrists knew instinctively: that those with minor and reactive depression fare better with cognitive therapy and interpersonal counselling than with drug treatment.

“The whole Prozac story is a cautionary tale,” says Prof Shorter. “When it comes to both diagnosis and treatment, the early approaches are very often better.”

Dizzy at springtime

The conundrum featured in this column of the lady whose mild vertigo when lying down or turning over in bed is exacerbated around the spring equinox has prompted the idea that this must be due to changes in pressure in the middle ear – for which there are two possible explanations.

The first would be a hayfever-type allergy, where sensitivity to pollens in late March causes narrowing of the Eustachian tube at the back of the throat, preventing fluid draining from the middle ear and adversely affecting balance.

Next, readers point out that the weather is often unsettled at this time of year (hence March “coming in like a lion and going out like a lamb”). The fall in barometric pressure in the days prior to a storm, for example, would cause the fluid in the middle ear to expand, with similar consequences.

Mystery stomach pain

This week’s medical query comes courtesy of Mr HJ from Leeds, writing on behalf of his 12-year-old grandson, who has Type 1 diabetes. This is well-controlled on his current insulin regime, but for months he has been troubled by a constant abdominal pain of such severity as to wake him at night, affecting his schooling due to exhaustion.

The usual scans and X-rays have failed to identify a cause and he has been labelled as having “chronic non-organic abdominal pain”, with the implications that the problem is psychological rather than physical. This clearly cannot be the case. Does anyone, he wonders, have a suggestion as to what might be amiss?